Effective capture test

ABSTRACT

The present disclosure pertains to cardiac pacing methods and systems, and, more particularly, to cardiac resynchronization therapy (CRT). In particular, the present disclosure pertains to determining the efficacy of CRT through use of an effective capture test (ECT). One or more embodiments comprises sensing a signal in response to a ventricular pacing stimulus. Through signal processing, a number of features are parsed from the signal. Exemplary features parsed from the signal include a maximum amplitude, a maximum time associated with the maximum amplitude, a minimum amplitude, and a minimum time associated with the minimum amplitude. The data is evaluated through use of the ECT. By employing the ECT, efficacy of CRT is easily and automatically evaluated.

FIELD

The present disclosure pertains to cardiac pacing methods and systems,and, more particularly, to cardiac resynchronization therapy (CRT).

BACKGROUND

Cardiac resynchronization cardiac pacing devices operate by eitherdelivering pacing stimulus to both ventricles or to one ventricle withthe desired result of a more or less simultaneous mechanical contractionand ejection of blood from the ventricles. Ideally, each pacing pulsestimulus delivered to a ventricle evokes a response from the ventricle.Delivering electrical stimuli that causes the ventricle to respond iscommonly referred to as capturing a ventricle. For a variety of reasons,cardiac pacing systems may not achieve effective capture of a ventricle.For example, a pacing lead and/or electrode may not be placed in anoptimal location. Sensed atrioventricular delay (SAV), pacedatrioventricular delay (PAV), right ventricular pre-excitation may alsoaffect whether a ventricle is effectively captured. Additionally, afterthe medical device has been implanted, migration or dislodgement of thepacing lead may occur. It is desirable to develop additional systems andmethods that automatically determine optimal effective capture of aventricle.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a diagram of an exemplary system including an exemplaryimplantable medical device (IMD).

FIG. 2 is a diagram of the exemplary IMD of FIG. 1.

FIG. 3A is a block diagram of an exemplary IMD, e.g., the IMD of FIGS.1-2.

FIG. 3B is yet another block diagram of one embodiment of IMD (e.g. IPG)circuitry and associated leads employed in the system of FIG. 2 forproviding three sensing channels and corresponding pacing channels thatselectively functions in a ventricular pacing mode providing ventricularcapture verification.

FIG. 4 is a flowchart of an exemplary method for determining whether anelectrical stimuli effectively captures a ventricle.

FIG. 5 graphically depicts data that supports an effective capture testdepicted in flowchart of FIG. 4.

FIG. 6 graphically depicts data, used in the flowchart of FIG. 4, inwhich effective capture has not occurred.

FIGS. 7A-7C graphically depicts data that supports an effective capturetest depicted in flowchart of FIG. 4.

FIG. 8 is a flowchart of an exemplary diagnostic method for use inexplaining electrical stimulus that is ineffectively capturing aventricle.

FIG. 9 is a flowchart of yet another exemplary diagnostic method for usein explaining electrical stimulus that is ineffectively capturing aventricle.

FIG. 10 is a graphical display of data obtained during evaluation ofcapture ineffectiveness for a pacing stimulus.

FIG. 11 is a graphical display of data obtained during evaluation ofcapture ineffectiveness due to atrial tachycardia/fibrillation and along paced atrioventricular delay (PAV) during biventricular pacing.

FIG. 12 depicts a graphical user interface of a programmer that explainsineffective capture of a ventricle is due to sensed atrioventriculardelay (SAV) and PAV.

FIG. 13 is a flowchart of an exemplary method that automatically adjustssettings on an implantable medical device to more effectively capture aventricle.

FIG. 14 is an exemplary graphical user interface that alerts a physicianas to a condition in a patient.

FIG. 15 is an exemplary graphical user interface that tracks heartfunction and device function.

DETAILED DESCRIPTION OF EXEMPLARY EMBODIMENTS

In the following detailed description, references are made toillustrative embodiments for carrying out methods of confirming pacingcapture of ventricular pacing stimulation. It is understood that otherembodiments may be utilized without departing from the scope of theinvention. For example, the invention is disclosed in detail herein inthe context of a bi-ventricular cardiac resynchronization therapy (CRT)delivery.

Exemplary methods, devices, and systems shall be described withreference to FIGS. 1-15. It will be apparent to one skilled in the artthat elements or processes from one embodiment may be used incombination with elements or processes of the other embodiments, andthat the possible embodiments of such methods, devices, and systemsusing combinations of features set forth herein is not limited to thespecific embodiments shown in the Figures and/or described herein.Further, it will be recognized that the embodiments described herein mayinclude many elements that are not necessarily shown to scale.

The term “effective capture test,” employs elements parsed from a signalsensed from the ventricle. A sensed signal from a ventricle includes amaximum amplitude (Max), a maximum time (Tmax) associated with themaximum amplitude (Max), a minimum amplitude (Min), and a minimum time(Tmin) associated with the minimum amplitude. The effective capture testis based upon one or more of:

Tmax−Tmin>30 ms  (1)

0.2<|Max−a baseline (BL)|/|BL−Min|<5;  (2)

(|Max−BL|/|Min−BL|≦LL and BL<|Min/8|)  (3)

Tmin<60 ms; and  (4)

Max−Min>3.5 mV.  (5)

The effective capture test, typically performed daily, determineswhether effective capture of a ventricle is occurring after theimplantable medical device has been implanted in a patient. Theeffective capture test uses ideal pace timing conditions for a few beatsduring the effective capture test. Ideal pace timing conditions meansthat the normal pace timing is modified to increase the chances ofeffective capture. If effective capture is not achieved during idealpace timing conditions, then effective capture cannot be achieved duringnormal daily monitoring to pace therapy. Normal daily monitoring to pacetherapy is referred to herein as capture monitoring and is typicallyperformed at a rate of 100 beats/hour.

The present disclosure is able to achieve effective capture bydelivering pacing stimuli at sufficient energy and at the proper timing,which provides beneficial results over known capture managementalgorithms. While capture management algorithms are able to artificiallymodify the timing (i.e., overdrive pace or use very short SAV/PAV), themain focus of capture management algorithms is on sufficient energydelivery of a pacing stimulus. Capture management algorithms generallydo not address proper timing and cannot be used to assess effectivecapture during normal device operation.

In one or more embodiments, the present disclosure determines theefficacy of CRT by sensing a signal in response to a ventricular pacingstimulus. A processor determines whether a positive deflection of thesignal precedes a negative deflection of the signal. A determination ismade as to whether the ventricular pacing stimulus is capturing thepaced ventricle in response to determining whether the positivedeflection precedes the negative deflection.

In one or more embodiments, the present disclosure determines theefficacy of CRT by sensing a signal in response to a ventricular pacingstimulus. Through signal processing, a number of features are parsedfrom the signal such as maximum amplitude, a maximum time associatedwith the maximum amplitude, a minimum amplitude, and a minimum timeassociated with the minimum amplitude. Thereafter, a determination ismade as to whether the maximum time minus the minimum time is greaterthan a preselected threshold. In one or more other embodiments, afraction is calculated. The numerator of the fraction is equal to themaximum amplitude minus a baseline. The denominator is equal to thebaseline minus the minimum amplitude. A determination is then made as towhether the fraction is greater than a lower limit and whether thefraction is less than an upper limit. In response to determining whetherthe fraction is greater than the lower limit and whether the fraction isless than the upper limit, a determination is made as to whether theventricular pacing stimulus is capturing the paced ventricle. In yet oneor more embodiments, a determination is made as whether the minimum timeis less than a predetermined time. By employing these simple criteria,efficacy of CRT is easily and automatically evaluated.

In one or more other embodiments, reasons for ineffective capture aredisplayed to a user on a graphical user interface of a programmer.Exemplary reasons for ineffective capture include a sensedatrioventricular delay (SAV) that is too long, a paced atrioventriculardelay (PAV) that is too long, RV pre-excitation, AF, a medicalelectrical lead placed in scar tissue, loss of capture due to leaddislodgement, atrial under sensing, a rate above an upper tracking rate,and the right and left ventricular leads are too close. A SAV that istoo long, a PAV that is too long and RV pre-excitation can all beautomatically addressed through adjusting delivery of the electricalstimuli to the ventricle.

FIG. 1 is a conceptual diagram illustrating an exemplary therapy system10 that may be used to deliver pacing therapy to a patient 14. Patient14 may, but not necessarily, be a human. The therapy system 10 mayinclude an implantable medical device 16 (IMD), which may be coupled toleads 18, 20, 22 and a programmer 24. The IMD 16 may be, e.g., animplantable pacemaker, cardioverter, and/or defibrillator, that provideselectrical signals to the heart 12 of the patient 14 via electrodescoupled to one or more of the leads 18, 20, 22.

The leads 18, 20, 22 extend into the heart 12 of the patient 14 to senseelectrical activity of the heart 12 and/or to deliver electricalstimulation to the heart 12. In the example shown in FIG. 1, the rightventricular (RV) lead 18 extends through one or more veins (not shown),the superior vena cava (not shown), and the right atrium 26, and intothe right ventricle 28. The left ventricular (LV) coronary sinus lead 20extends through one or more veins, the vena cava, the right atrium 26,and into the coronary sinus 30 to a region adjacent to the free wall ofthe left ventricle 32 of the heart 12. The right atrial (RA) lead 22extends through one or more veins and the vena cava, and into the rightatrium 26 of the heart 12.

The IMD 16 may sense, among other things, electrical signals attendantto the depolarization and repolarization of the heart 12 via electrodescoupled to at least one of the leads 18, 20, 22. In some examples, theIMD 16 provides pacing therapy (e.g., pacing pulses) to the heart 12based on the electrical signals sensed within the heart 12. The IMD 16may be operable to adjust one or more parameters associated with thepacing therapy such as, e.g., pulse wide, amplitude, voltage, burstlength, etc. Further, the IMD 16 may be operable to use variouselectrode configurations to deliver pacing therapy, which may beunipolar or bipolar. The IMD 16 may also provide defibrillation therapyand/or cardioversion therapy via electrodes located on at least one ofthe leads 18, 20, 22. Further, the IMD 16 may detect arrhythmia of theheart 12, such as fibrillation of the ventricles 28, 32, and deliverdefibrillation therapy to the heart 12 in the form of electrical pulses.In some examples, IMD 16 may be programmed to deliver a progression oftherapies, e.g., pulses with increasing energy levels, until afibrillation of heart 12 is stopped.

In some examples, a programmer 24, which may be a handheld computingdevice or a computer workstation, may be used by a user, such as aphysician, technician, another clinician, and/or patient, to communicatewith the IMD 16 (e.g., to program the IMD 16). For example, the user mayinteract with the programmer 24 to retrieve information concerning oneor more detected or indicated faults associated within the IMD 16 and/orthe pacing therapy delivered therewith. The IMD 16 and the programmer 24may communicate via wireless communication using any techniques known inthe art. Examples of communication techniques may include, e.g., lowfrequency or radiofrequency (RF) telemetry, but other techniques arealso contemplated.

FIG. 2 is a conceptual diagram illustrating the IMD 16 and the leads 18,20, 22 of therapy system 10 of FIG. 1 in more detail. The leads 18, 20,22 may be electrically coupled to a therapy delivery module (e.g., fordelivery of pacing therapy), a sensing module (e.g., one or moreelectrodes to sense or monitor electrical activity of the heart 12 foruse in determining effectiveness of pacing therapy), and/or any othermodules of the IMD 16 via a connector block 34. In some examples, theproximal ends of the leads 18, 20, 22 may include electrical contactsthat electrically couple to respective electrical contacts within theconnector block 34 of the IMD 16. In addition, in some examples, theleads 18, 20, 22 may be mechanically coupled to the connector block 34with the aid of set screws, connection pins, or another suitablemechanical coupling mechanism.

Each of the leads 18, 20, 22 includes an elongated insulative lead body,which may carry a number of conductors (e.g., concentric coiledconductors, straight conductors, etc.) separated from one another byinsulation (e.g., tubular insulative sheaths). In the illustratedexample, bipolar electrodes 40, 42 are located proximate to a distal endof the lead 18. In addition, the bipolar electrodes 44, 46 are locatedproximate to a distal end of the lead 20 and the bipolar electrodes 48,50 are located proximate to a distal end of the lead 22.

The electrodes 40, 44, 48 may take the form of ring electrodes, and theelectrodes 42, 46, 50 may take the form of extendable helix tipelectrodes mounted retractably within the insulative electrode heads 52,54, 56, respectively. Each of the electrodes 40, 42, 44, 46, 48, 50 maybe electrically coupled to a respective one of the conductors (e.g.,coiled and/or straight) within the lead body of its associated lead 18,20, 22, and thereby coupled to respective ones of the electricalcontacts on the proximal end of the leads 18, 20, 22.

The electrodes 40, 42, 44, 46, 48, 50 may further be used to senseelectrical signals (e.g., morphological waveforms within electrograms(EGM)) attendant to the depolarization and repolarization of the heart12. The electrical signals are conducted to the IMD 16 via therespective leads 18, 20, 22. In some examples, the IMD 16 may alsodeliver pacing pulses via the electrodes 40, 42, 44, 46, 48, 50 to causedepolarization of cardiac tissue of the patient's heart 12. In someexamples, as illustrated in FIG. 2, the IMD 16 includes one or morehousing electrodes, such as housing electrode 58, which may be formedintegrally with an outer surface of a housing 60 (e.g.,hermetically-sealed housing) of the IMD 16 or otherwise coupled to thehousing 60. Any of the electrodes 40, 42, 44, 46, 48, 50 may be used forunipolar sensing or pacing in combination with housing electrode 58. Inother words, any of electrodes 40, 42, 44, 46, 48, 50, 58 may be used incombination to form a sensing vector, e.g., a sensing vector that may beused to evaluate and/or analysis the effectiveness of pacing therapy. Anexample of a configuration sensing and pacing may be seen with respectto U.S. Pat. Application No. 61/580,058 filed Dec. 23, 2011, andassigned to the assignee of the present invention, the disclosure ofwhich is incorporated by reference in its entirety herein as modified bypreferably using a LVtip (i.e. electrode 46)—Rvcoil (i.e. electrode 62)for the pacing vector and the sensing vector. It is generally understoodby those skilled in the art that other electrodes can also be selectedas pacing and sensing vectors. Electrode 44 and 64 refer to the thirdand fourth LV electrodes in the claims.

As described in further detail with reference to FIGS. 3A-3B, thehousing 60 may enclose a therapy delivery module that may include astimulation generator for generating cardiac pacing pulses anddefibrillation or cardioversion shocks, as well as a sensing module formonitoring the patient's heart rhythm. The leads 18, 20, 22 may alsoinclude elongated electrodes 62, 64, 66, respectively, which may takethe form of a coil. The IMD 16 may deliver defibrillation shocks to theheart 12 via any combination of the elongated electrodes 62, 64, 66 andthe housing electrode 58. The electrodes 58, 62, 64, 66 may also be usedto deliver cardioversion pulses to the heart 12. Further, the electrodes62, 64, 66 may be fabricated from any suitable electrically conductivematerial, such as, but not limited to, platinum, platinum alloy, and/orother materials known to be usable in implantable defibrillationelectrodes. Since electrodes 62, 64, 66 are not generally configured todeliver pacing therapy, any of electrodes 62, 64, 66 may be used tosense electrical activity during pacing therapy (e.g., for use inanalyzing pacing therapy effectiveness) and may be used in combinationwith any of electrodes 40, 42, 44, 46, 48, 50, 58. In at least oneembodiment, the RV elongated electrode 62 may be used to senseelectrical activity of a patient's heart during the delivery of pacingtherapy (e.g., in combination with the housing electrode 58 forming a RVelongated, coil, or defibrillation electrode-to-housing electrodevector).

The configuration of the exemplary therapy system 10 illustrated inFIGS. 1-2 is merely one example. In other examples, the therapy systemmay include epicardial leads and/or patch electrodes instead of or inaddition to the transvenous leads 18, 20, 22 illustrated in FIG. 1.Further, in one or more embodiments, the IMD 16 need not be implantedwithin the patient 14. For example, the IMD 16 may deliverdefibrillation shocks and other therapies to the heart 12 viapercutaneous leads that extend through the skin of the patient 14 to avariety of positions within or outside of the heart 12. In one or moreembodiments, the system 10 may utilize wireless pacing (e.g., usingenergy transmission to the intracardiac pacing component(s) viaultrasound, inductive coupling, RF, etc.) and sensing cardiac activationusing electrodes on the can/housing and/or on subcutaneous leads.

In other examples of therapy systems that provide electrical stimulationtherapy to the heart 12, such therapy systems may include any suitablenumber of leads coupled to the IMD 16, and each of the leads may extendto any location within or proximate to the heart 12. For example, otherexamples of therapy systems may include three transvenous leads locatedas illustrated in FIGS. 1-2. Still further, other therapy systems mayinclude a single lead that extends from the IMD 16 into the right atrium26 or the right ventricle 28, or two leads that extend into a respectiveone of the right atrium 26 and the right ventricle 28.

FIG. 3A is a functional block diagram of one exemplary configuration ofthe IMD 16. As shown, the IMD 16 may include a control module 81, atherapy delivery module 84 (e.g., which may include a stimulationgenerator), a sensing module 86, and a power source 90.

The control module 81 may include a processor 80, memory 82, and atelemetry module 88. The memory 82 may include computer-readableinstructions that, when executed, e.g., by the processor 80, cause theIMD 16 and/or the control module 81 to perform various functionsattributed to the IMD 16 and/or the control module 81 described herein.Further, the memory 82 may include any volatile, non-volatile, magnetic,optical, and/or electrical media, such as a random access memory (RAM),read-only memory (ROM), non-volatile RAM (NVRAM), electrically-erasableprogrammable ROM (EEPROM), flash memory, and/or any other digital media.Memory 82 includes computer instructions related to capture management.An exemplary capture management module such as left ventricular capturemanagement (LVCM) is briefly described in U.S. Pat. No. 7,684,863, whichis incorporated by reference. As to the delivery of pacing stimuli,capture management algorithms typically focus on sufficient energydelivery of a pacing stimulus.

The processor 80 of the control module 81 may include any one or more ofa microprocessor, a controller, a digital signal processor (DSP), anapplication specific integrated circuit (ASIC), a field-programmablegate array (FPGA), and/or equivalent discrete or integrated logiccircuitry. In some examples, the processor 80 may include multiplecomponents, such as any combination of one or more microprocessors, oneor more controllers, one or more DSPs, one or more ASICs, and/or one ormore FPGAs, as well as other discrete or integrated logic circuitry. Thefunctions attributed to the processor 80 herein may be embodied assoftware, firmware, hardware, or any combination thereof.

The control module 81 may control the therapy delivery module 84 todeliver therapy (e.g., electrical stimulation therapy such as pacing) tothe heart 12 according to a selected one or more therapy programs, whichmay be stored in the memory 82. More, specifically, the control module81 (e.g., the processor 80) may control the therapy delivery module 84to deliver electrical stimulus such as, e.g., pacing pulses with theamplitudes, pulse widths, frequency, or electrode polarities specifiedby the selected one or more therapy programs (e.g., pacing therapyprograms, pacing recovery programs, capture management programs, etc.).As shown, the therapy delivery module 84 is electrically coupled toelectrodes 40, 42, 44, 46, 48, 50, 58, 62, 64, 66, e.g., via conductorsof the respective lead 18, 20, 22, or, in the case of housing electrode58, via an electrical conductor disposed within housing 60 of IMD 16.Therapy delivery module 84 may be configured to generate and deliverelectrical stimulation therapy such as pacing therapy to the heart 12using one or more of the electrodes 40, 42, 44, 46, 48, 50, 58, 62, 64,66.

For example, therapy delivery module 84 may deliver pacing stimulus(e.g., pacing pulses) via ring electrodes 40, 44, 48 coupled to leads18, 20, and 22, respectively, and/or helical tip electrodes 42, 46, and50 of leads 18, 20, and 22, respectively. Further, for example, therapydelivery module 84 may deliver defibrillation shocks to heart 12 via atleast two of electrodes 58, 62, 64, 66. In some examples, therapydelivery module 84 may be configured to deliver pacing, cardioversion,or defibrillation stimulation in the form of electrical pulses. In otherexamples, therapy delivery module 84 may be configured deliver one ormore of these types of stimulation in the form of other signals, such assine waves, square waves, and/or other substantially continuous timesignals.

The IMD 16 may further include a switch module 85 and the control module81 (e.g., the processor 80) may use the switch module 85 to select,e.g., via a data/address bus, which of the available electrodes are usedto deliver therapy such as pacing pulses for pacing therapy, or which ofthe available electrodes are used for sensing. The switch module 85 mayinclude a switch array, switch matrix, multiplexer, or any other type ofswitching device suitable to selectively couple the sensing module 86and/or the therapy delivery module 84 to one or more selectedelectrodes. More specifically, the therapy delivery module 84 mayinclude a plurality of pacing output circuits. Each pacing outputcircuit of the plurality of pacing output circuits may be selectivelycoupled, e.g., using the switch module 85, to one or more of theelectrodes 40, 42, 44, 46, 48, 50, 58, 62, 64, 66 (e.g., a pair ofelectrodes for delivery of therapy to a pacing vector). In other words,each electrode can be selectively coupled to one of the pacing outputcircuits of the therapy delivery module using the switching module 85.

The sensing module 86 is coupled (e.g., electrically coupled) to sensingapparatus, which may include, among additional sensing apparatus, theelectrodes 40, 42, 44, 46, 48, 50, 58, 62, 64, 66 to monitor electricalactivity of the heart 12, e.g., electrocardiogram (ECG)/electrogram(EGM) signals, etc. The ECG/EGM signals may be used to analyze of aplurality of paced events. More specifically, one or more morphologicalfeatures of each paced event within the ECG/EGM signals may be used todetermine whether each paced event has a predetermined level ofeffectiveness. The ECG/EGM signals may be further used to monitor heartrate (HR), heart rate variability (HRV), heart rate turbulence (HRT),deceleration/acceleration capacity, deceleration sequence incidence,T-wave alternans (TWA), P-wave to P-wave intervals (also referred to asthe P-P intervals or A-A intervals), R-wave to R-wave intervals (alsoreferred to as the R-R intervals or V-V intervals), P-wave to QRScomplex intervals (also referred to as the P-R intervals, A-V intervals,or P-Q intervals), QRS-complex morphology, ST segment (i.e., the segmentthat connects the QRS complex and the T-wave), T-wave changes, QTintervals, electrical vectors, etc.

The switch module 85 may be also be used with the sensing module 86 toselect which of the available electrodes are used to, e.g., senseelectrical activity of the patient's heart (e.g., one or more electricalvectors of the patient's heart using any combination of the electrodes40, 42, 44, 46, 48, 50, 58, 62, 64, 66). In some examples, the controlmodule 81 may select the electrodes that function as sensing electrodesvia the switch module within the sensing module 86, e.g., by providingsignals via a data/address bus. In some examples, the sensing module 86may include one or more sensing channels, each of which may include anamplifier.

In some examples, sensing module 86 includes a channel that includes anamplifier with a relatively wider pass band than the R-wave or P-waveamplifiers. Signals from the selected sensing electrodes that areselected for coupling to this wide-band amplifier may be provided to amultiplexer, and thereafter converted to multi-bit digital signals by ananalog-to-digital converter for storage in memory 82 as an EGM. In someexamples, the storage of such EGMs in memory 82 may be under the controlof a direct memory access circuit. The control module 81 (e.g., usingthe processor 80) may employ digital signal analysis techniques tocharacterize the digitized signals stored in memory 82 to analyze and/orclassify one or more morphological waveforms of the EGM signals todetermine pacing therapy effectiveness. For example, the processor 80may be configured to determine, or obtain, one more features of one ormore sensed morphological waveforms within one of more electricalvectors of the patient's heart and store the one or more features withinthe memory 82 for use in determining effectiveness of pacing therapy ata later time.

If IMD 16 is configured to generate and deliver pacing pulses to theheart 12, the control module 81 may include a pacer timing and controlmodule, which may be embodied as hardware, firmware, software, or anycombination thereof. The pacer timing and control module may include oneor more dedicated hardware circuits, such as an ASIC, separate from theprocessor 80, such as a microprocessor, and/or a software moduleexecuted by a component of processor 80, which may be a microprocessoror ASIC. The pacer timing and control module may include programmablecounters which control the basic time intervals associated with DDD, WI,DVI, VDD, AAI, DDI, DDDR, VVIR, DVIR, VDDR, AAIR, DDIR and other modesof single and dual chamber pacing. In the aforementioned pacing modes,“D” may indicate dual chamber, “V” may indicate a ventricle, “I” mayindicate inhibited pacing (e.g., no pacing), and “A” may indicate anatrium. The first letter in the pacing mode may indicate the chamberthat is paced, the second letter may indicate the chamber in which anelectrical signal is sensed, and the third letter may indicate thechamber in which the response to sensing is provided.

Intervals defined by the pacer timing and control module within controlmodule 81 may include atrial and ventricular pacing escape intervals,refractory periods during which sensed P-waves and R-waves areineffective to restart timing of the escape intervals, and/or the pulsewidths of the pacing pulses. As another example, the pacer timing andcontrol module may define a blanking period, and provide signals fromsensing module 86 to blank one or more channels, e.g., amplifiers, for aperiod during and after delivery of electrical stimulation to the heart12. The durations of these intervals may be determined in response tostored data in memory 82. The pacer timing and control module of thecontrol module 81 may also determine the amplitude of the cardiac pacingpulses.

During pacing, escape interval counters within the pacer timing/controlmodule may be reset upon sensing of R-waves and P-waves. Therapydelivery module 84 (e.g., including a stimulation generator) may includeone or more pacing output circuits that are coupled, e.g., selectivelyby the switch module 85, to any combination of electrodes 40, 42, 44,46, 48, 50, 58, 62, or 66 appropriate for delivery of a bipolar orunipolar pacing pulse to one of the chambers of heart 12. The controlmodule 81 may reset the escape interval counters upon the generation ofpacing pulses by therapy delivery module 84, and thereby control thebasic timing of cardiac pacing functions, including anti-tachyarrhythmiapacing.

In some examples, the control module 81 may operate as an interruptdriven device, and may be responsive to interrupts from pacer timing andcontrol module, where the interrupts may correspond to the occurrencesof sensed P-waves and R-waves and the generation of cardiac pacingpulses. Any necessary mathematical calculations may be performed by theprocessor 80 and any updating of the values or intervals controlled bythe pacer timing and control module may take place following suchinterrupts. A portion of memory 82 may be configured as a plurality ofrecirculating buffers, capable of holding series of measured intervals,which may be analyzed by, e.g., the processor 80 in response to theoccurrence of a pace or sense interrupt to determine whether thepatient's heart 12 is presently exhibiting atrial or ventriculartachyarrhythmia.

The telemetry module 88 of the control module 81 may include anysuitable hardware, firmware, software, or any combination thereof forcommunicating with another device, such as the programmer 24 asdescribed herein with respect to FIG. 1. For example, under the controlof the processor 80, the telemetry module 88 may receive downlinktelemetry from and send uplink telemetry to the programmer 24 with theaid of an antenna, which may be internal and/or external. The processor80 may provide the data to be uplinked to the programmer 24 and thecontrol signals for the telemetry circuit within the telemetry module88, e.g., via an address/data bus. In some examples, the telemetrymodule 88 may provide received data to the processor 80 via amultiplexer. In at least one embodiment, the telemetry module 88 may beconfigured to transmit an alarm, or alert, if the pacing therapy becomesineffective or less effective (e.g., does not have a predetermined levelof effectiveness).

The various components of the IMD 16 are further coupled to a powersource 90, which may include a rechargeable or non-rechargeable battery.A non-rechargeable battery may be selected to last for several years,while a rechargeable battery may be inductively charged from an externaldevice, e.g., on a daily or weekly basis.

A pacing (e.g., for LV and/or BV pacing) ratio or percentage, which isthe number of paced heart beats divided by the total number of heartbeats, often expressed as a percentage of the total number of heartbeats, may be a useful metric for evaluating the effectiveness of CRTbut, in many cases, it may be misleading because a high pacing ratio orpercentage may not necessarily mean that CRT is effective if, e.g.,ventricular pacing fails to properly alter electrical activationpatterns. Automatic beat-to-beat analysis of the evoked response (e.g.,paced QRS complexes) in monitored EGM signals may be used to determinewhether the paced heartbeat was effectively paced, and hence, to providemore resolution to a pacing ratio. For example, the heartbeats that werepaced but determined to not be effectively paced (e.g., depending on thedegree of fusion between intrinsic and paced activation, etc.) may beexcluded from the pacing ratio thereby providing a more accurate metricof pacing efficacy and/or efficiency, which may referred to as a pacingeffectiveness ratio.

A feature-based classification may enable beat-to-beat rhythmclassification in a device (e.g., IMD 16) employing cardiac pacing(e.g., left ventricular fusion pacing, biventricular pacing, etc.) andmay add value to the device by providing useful diagnostic indices to aphysician. The computational price involved in such feature-basedbeat-to-beat classifications may be minimal and may be implementedwithin the architecture of devices such as the IMD 16 described hereinwith reference to FIGS. 1-3B. For example, the exemplary methodsdescribed herein may combine algebraic operations and comparisons and/ormay require a single normalization per beat compared to multipleintensive mathematical operations and normalizations that are oftenrequired for detailed template matching algorithms.

FIG. 3B is yet another embodiment of a functional block diagram for IMD16. FIG. 3B depicts bipolar RA lead 22, bipolar RV lead 18, and bipolarLV CS lead 20 without the LA CS pace/sense electrodes 28 and 30 coupledwith an IPG circuit 31 having programmable modes and parameters of abi-ventricular DDD/R type known in the pacing art. In turn, the sensorsignal processing circuit 43 indirectly couples to the timing circuit 83and via data and control bus to microcomputer circuitry 33. The IPGcircuit 31 is illustrated in a functional block diagram dividedgenerally into a microcomputer circuit 33 and a pacing circuit 83. Thepacing circuit 83 includes the digital controller/timer circuit 83, theoutput amplifiers circuit 51, the sense amplifiers circuit 55, the RFtelemetry transceiver 41, the activity sensor circuit 35 as well as anumber of other circuits and components described below.

Crystal oscillator circuit 47 provides the basic timing clock for thepacing circuit 320, while battery 29 provides power. Power-on-resetcircuit 45 responds to initial connection of the circuit to the batteryfor defining an initial operating condition and similarly, resets theoperative state of the device in response to detection of a low batterycondition. Reference mode circuit 37 generates stable voltage referenceand currents for the analog circuits within the pacing circuit 320,while analog to digital converter ADC and multiplexer circuit 39digitizes analog signals and voltage to provide real time telemetry if acardiac signals from sense amplifiers 55, for uplink transmission via RFtransmitter and receiver circuit 41. Voltage reference and bias circuit37, ADC and multiplexer 39, power-on-reset circuit 45 and crystaloscillator circuit 47 may correspond to any of those presently used incurrent marketed implantable cardiac pacemakers.

If the IPG is programmed to a rate responsive mode, the signals outputby one or more physiologic sensor are employed as a rate controlparameter (RCP) to derive a physiologic escape interval. For example,the escape interval is adjusted proportionally the patient's activitylevel developed in the patient activity sensor (PAS) circuit 35 in thedepicted, exemplary IPG circuit 31. The patient activity sensor 316 iscoupled to the IPG housing and may take the form of a piezoelectriccrystal transducer as is well known in the art and its output signal isprocessed and used as the RCP. Sensor 316 generates electrical signalsin response to sensed physical activity that are processed by activitycircuit 35 and provided to digital controller/timer circuit 83. Activitycircuit 35 and associated sensor 316 may correspond to the circuitrydisclosed in U.S. Pat. Nos. 5,052,388 and 4,428,378. Similarly, thepresent invention may be practiced in conjunction with alternate typesof sensors such as oxygenation sensors, pressure sensors, pH sensors andrespiration sensors, all well known for use in providing rate responsivepacing capabilities. Alternately, QT time may be used as the rateindicating parameter, in which case no extra sensor is required.Similarly, the present invention may also be practiced in non-rateresponsive pacemakers.

Data transmission to and from the external programmer is accomplished bymeans of the telemetry antenna 57 and an associated RF transceiver 41,which serves both to demodulate received downlink telemetry and totransmit uplink telemetry. Uplink telemetry capabilities will typicallyinclude the ability to transmit stored digital information, e.g.operating modes and parameters, EGM histograms, and other events, aswell as real time EGMs of atrial and/or ventricular electrical activityand Marker Channel pulses indicating the occurrence of sensed and paceddepolarizations in the atrium and ventricle, as are well known in thepacing art.

Microcomputer 33 contains a microprocessor 80 and associated systemclock and on-processor RAM and ROM chips 82A and 82B, respectively. Inaddition, microcomputer circuit 33 includes a separate RAM/ROM chip 82Cto provide additional memory capacity. Microprocessor 80 normallyoperates in a reduced power consumption mode and is interrupt driven.Microprocessor 80 is awakened in response to defined interrupt events,which may include A-TRIG, RV-TRIG, LV-TRIG signals generated by timersin digital timer/controller circuit 83 and A-EVENT, RV-EVENT, andLV-EVENT signals generated by sense amplifiers circuit 55, among others.The specific values of the intervals and delays timed out by digitalcontroller/timer circuit 83 are controlled by the microcomputer circuit33 by means of data and control bus 306 from programmed-in parametervalues and operating modes. In addition, if programmed to operate as arate responsive pacemaker, a timed interrupt, e.g., every cycle or everytwo seconds, may be provided in order to allow the microprocessor toanalyze the activity sensor data and update the basic A-A, V-A, or V-Vescape interval, as applicable. In addition, the microprocessor 80 mayalso serve to define variable, operative AV delay intervals and theenergy delivered to each ventricle.

In one embodiment, microprocessor 80 is a custom microprocessor adaptedto fetch and execute instructions stored in RAM/ROM unit 314 in aconventional manner. It is contemplated, however, that otherimplementations may be suitable to practice the present invention. Forexample, an off-the-shelf, commercially available microprocessor ormicrocontroller, or custom application-specific, hardwired logic, orstate-machine type circuit may perform the functions of microprocessor80.

Digital controller/timer circuit 83 operates under the general controlof the microcomputer 33 to control timing and other functions within thepacing circuit 320 and includes a set of timing and associated logiccircuits of which certain ones pertinent to the present invention aredepicted. The depicted timing circuits include URI/LRI timers 83A, V-Vdelay timer 83B, intrinsic interval timers 83C for timing elapsedV-EVENT to V-EVENT intervals or V-EVENT to A-EVENT intervals or the V-Vconduction interval, escape interval timers 83D for timing A-A, V-A,and/or V-V pacing escape intervals, an AV delay interval timer 83E fortiming the A-LVp delay (or A-RVp delay) from a preceding A-EVENT orA-TRIG, a post-ventricular timer 374 for timing post-ventricular timeperiods, and a date/time clock 376.

The AV delay interval timer 83E is loaded with an appropriate delayinterval for one ventricular chamber (i.e., either an A-RVp delay or anA-LVp delay as determined using known methods) to time-out starting froma preceding A-PACE or A-EVENT. The interval timer 83E triggers pacingstimulus delivery, and can based on one or more prior cardiac cycles (orfrom a data set empirically derived for a given patient).

The post-event timers 374 time out the post-ventricular time periodsfollowing an RV-EVENT or LV-EVENT or a RV-TRIG or LV-TRIG andpost-atrial time periods following an A-EVENT or A-TRIG. The durationsof the post-event time periods may also be selected as programmableparameters stored in the microcomputer 33. The post-ventricular timeperiods include the PVARP, a post-atrial ventricular blanking period(PAVBP), a ventricular blanking period (VBP), a post-ventricular atrialblanking period (PVARP) and a ventricular refractory period (VRP)although other periods can be suitably defined depending, at least inpart, on the operative circuitry employed in the pacing engine. Thepost-atrial time periods include an atrial refractory period (ARP)during which an A-EVENT is ignored for the purpose of resetting any AVdelay, and an atrial blanking period (ABP) during which atrial sensingis disabled. It should be noted that the starting of the post-atrialtime periods and the AV delays can be commenced substantiallysimultaneously with the start or end of each A-EVENT or A-TRIG or, inthe latter case, upon the end of the A-PACE which may follow the A-TRIG.Similarly, the starting of the post-ventricular time periods and the V-Aescape interval can be commenced substantially simultaneously with thestart or end of the V-EVENT or V-TRIG or, in the latter case, upon theend of the V-PACE which may follow the V-TRIG. The microprocessor 80also optionally calculates AV delays, post-ventricular time periods, andpost-atrial time periods that vary with the sensor based escape intervalestablished in response to the RCP(s) and/or with the intrinsic atrialrate.

The output amplifiers circuit 51 contains a RA pace pulse generator (anda LA pace pulse generator if LA pacing is provided), a RV pace pulsegenerator, and a LV pace pulse generator or corresponding to any ofthose presently employed in commercially marketed cardiac pacemakersproviding atrial and ventricular pacing. In order to trigger generationof an RV-PACE or LV-PACE pulse, digital controller/timer circuit 83generates the RV-TRIG signal at the time-out of the A-RVp delay (in thecase of RV pre-excitation) or the LV-TRIG at the time-out of the A-LVpdelay (in the case of LV pre-excitation) provided by AV delay intervaltimer 83E (or the V-V delay timer 83B). Similarly, digitalcontroller/timer circuit 83 generates an RA-TRIG signal that triggersoutput of an RA-PACE pulse (or an LA-TRIG signal that triggers output ofan LA-PACE pulse, if provided) at the end of the V-A escape intervaltimed by escape interval timers 83D.

The output amplifiers circuit 51 includes switching circuits forcoupling selected pace electrode pairs from among the lead conductorsand the IND_CAN electrode 20 to the RA pace pulse generator (and LA pacepulse generator if provided), RV pace pulse generator and LV pace pulsegenerator. Pace/sense electrode pair selection and control circuit 53selects lead conductors and associated pace electrode pairs to becoupled with the atrial and ventricular output amplifiers within outputamplifiers circuit 51 for accomplishing RA, LA, RV and LV pacing.

The sense amplifiers circuit 55 contains sense amplifiers correspondingto any of those presently employed in contemporary cardiac pacemakersfor atrial and ventricular pacing and sensing. As noted in theabove-referenced, commonly assigned, '324 patent, it has been common inthe prior art to use very high impedance P-wave and R-wave senseamplifiers to amplify the voltage difference signal which is generatedacross the sense electrode pairs by the passage of cardiacdepolarization wavefronts. The high impedance sense amplifiers use highgain to amplify the low amplitude signals and rely on pass band filters,time domain filtering and amplitude threshold comparison to discriminatea P-wave or R-wave from background electrical noise. Digitalcontroller/timer circuit 83 controls sensitivity settings of the atrialand ventricular sense amplifiers 55.

The sense amplifiers are typically uncoupled from the sense electrodesduring the blanking periods before, during, and after delivery of a pacepulse to any of the pace electrodes of the pacing system to avoidsaturation of the sense amplifiers. The sense amplifiers circuit 55includes blanking circuits for uncoupling the selected pairs of the leadconductors and the IND_CAN electrode 20 from the inputs of the RA senseamplifier (and LA sense amplifier if provided), RV sense amplifier andLV sense amplifier during the ABP, PVABP and VBP. The sense amplifierscircuit 55 also includes switching circuits for coupling selected senseelectrode lead conductors and the IND_CAN electrode 20 to the RA senseamplifier (and LA sense amplifier if provided), RV sense amplifier andLV sense amplifier. Again, sense electrode selection and control circuit53 selects conductors and associated sense electrode pairs to be coupledwith the atrial and ventricular sense amplifiers within the outputamplifiers circuit 51 and sense amplifiers circuit 55 for accomplishingRA, LA, RV and LV sensing along desired unipolar and bipolar sensingvectors.

Right atrial depolarizations or P-waves in the RA-SENSE signal that aresensed by the RA sense amplifier result in a RA-EVENT signal that iscommunicated to the digital controller/timer circuit 83. Similarly, leftatrial depolarizations or P-waves in the LA-SENSE signal that are sensedby the LA sense amplifier, if provided, result in a LA-EVENT signal thatis communicated to the digital controller/timer circuit 83. Ventriculardepolarizations or R-waves in the RV-SENSE signal are sensed by aventricular sense amplifier result in an RV-EVENT signal that iscommunicated to the digital controller/timer circuit 83. Similarly,ventricular depolarizations or R-waves in the LV-SENSE signal are sensedby a ventricular sense amplifier result in an LV-EVENT signal that iscommunicated to the digital controller/timer circuit 83. The RV-EVENT,LV-EVENT, and RA-EVENT, LA-SENSE signals may be refractory ornon-refractory, and can inadvertently be triggered by electrical noisesignals or aberrantly conducted depolarization waves rather than trueR-waves or P-waves.

The exemplary methods and/or devices described herein may track, ormonitor, the effectiveness of pacing therapy by analyzing one or morefeatures of a sensed morphological waveform corresponding to a pacedevent for one or more monitored electrical vectors of the patient'sheart. As used herein, a sensed morphological waveform may correspond toa paced event by occurring within a predetermined, or selected, timeperiod, or sensing window, (e.g., 200 milliseconds) after the deliveryof pacing stimulus. The sensed morphological waveform may, e.g., resultfrom the delivery of pacing stimulus and/or intrinsic conduction.

FIG. 4 depicts a diagnostic method 500 for use in determining pacingeffectiveness in CRT pacing. In particular, morphological featuresfollowing delivery of a paced event are compared to absolute levels(i.e., thresholds that are not patient specific). For example, exemplarysystems and methods described herein monitor one or more electricalvectors of a patient's heart during pacing therapy, analyzing whethereach paced event has a predetermined level of effectiveness. In one ormore embodiments, morphological features are evaluated of a LV vector-RVcoil vector during LV only pacing or biventricular (BV) pacing in CRT.Exemplary LV vector-RV coiled vector can include electrode pairings suchas a LV tip (e.g. electrode 46) to RV coil (e.g. electrode 62), or LVring (e.g. electrode 54) to RV coil (e.g. electrode 62). It isadvantageous to select a monitoring vector that includes the LV pacingcathode and another electrode such as a RV coil or the IMD 16 case orhousing. For example, if LV pacing is occurring at the LV tip, then itis preferable to employ a monitoring vector of Lvtip-Rvcoil orLvtip-device case.

At block 502, a determination is made as to whether a current or latestventricular event is a paced event. If the device did not deliver apaced event, the NO path is followed, returning to block 502 to continuechecking for the next paced event. If a paced event has occurred, theYES path continues to optional block 504 so that the electrogram datafrom the monitored vector can be stored into memory. Block 504 isoptional since data storage can automatically occur independently of thecomputer instructions set forth in method 500. Exemplary EGM dataresulting from a paced event is depicted in FIG. 5. As shown, electricalstimuli (e.g. a biventricular pacing pulse) was delivered through amedical electrical lead to cardiac tissue at time=0 while the data issampled at an exemplary sampling frequency of 180 Hz (5.56 ms persample). Baseline data value (BL), used as a reference value, is sensedimmediately before a pacing stimulus is delivered. In the example ofFIG. 5, the device holds the baseline data value during a period ofblanking that immediately precedes and follows the delivery of a pacingstimulus, so the BL can also be sensed during the holding period (i.e.,immediately after a pacing stimulus is delivered). For example, the BLEGM amplitude is −1 and the minimum EGM amplitude is −110 where theunits are equal to the least significant bit (LSB) voltage of theanalog-to-digital converter (ADC). By way of illustration, if the fullscale voltage range of the ADC is 8 millivolts (mV) and the ADC has a 8bit resolution then the LSB voltage is 8*1000/(2⁸−1)=31.3 microvolts(μV). The timing of the minimum amplitude occurs at 6 time-samples(i.e., 33.4 milliseconds (ms)) from the time the pacing stimulus isinitially delivered to cardiac tissue. After the delivery of the pacingstimulus, the maximum EGM amplitude is 99 and the timing of the maximumamplitude is 14 time-samples (i.e. 78.4 ms).

To determine whether a pacing stimulus effectively captures a ventricle,sensed data is evaluated according to one or more of the mathematicalrelationships embodied at blocks 506, 508, 510, 516, 518, and 520. Atblock 506, a determination is made as to whether a first conditionrelative to effective capture is met. The first condition, presentedbelow, subtracts Tmin from Tmax and then determines whether the resultis greater than a predetermined threshold (T) such as 30 ms. Theequation for the first condition is as follows:

Tmax−Tmin>30 ms

If Tmax−Tmin is not greater than 30 ms, then the NO path continues toblock 514 in which the pacing stimulus is declared to ineffectivelycapture a ventricle. In contrast, if Tmax−Tmin>30 ms, the YES pathcontinues to block 508. The data presented in FIG. 5 provides an exampleof this condition being satisfied since Tmax−Tmin is equal to 78.4−33.4ms which equals 45 ms. At block 508, a determination is made as towhether a second condition is met. The equation for the second conditionis as follows:

LL<|Max−BL|/|BL−Min|<UL.

The lower limit (LL) and upper limit (UL) are associated with upper andlower ratio limits, respectively, of a morphological feature. ExemplaryLL can be 0.2 with a range of 0.1 to 0.33 and exemplary UL can be 5.0with a range of 3.0 to 10.0. Preferably, LL is set at 0.125 and the ULis set at 8.0.

The maximum value (Max) and the minimum value (Min) are associated witha particular EGM morphological feature such as amplitude. The ratio,|Max−BL|/|BL−Min|, includes the absolute value of Max−BL which isdivided by the absolute value of BL−Min. If the second condition atblock 508 is not satisfied, then the NO path continues to block 518 inwhich a determination is made as to whether (|Max−BL|/|Min−BL|)≦LL. If(|Max−BL|/|Min−BL|)≦LL is not met, then the NO path continues to block514 and the ventricular pace stimuli is declared not to evoke effectivecapture of the ventricle. In contrast, the YES path from block 518continues to block 520 in which a determination is made as to whetherBL<|Min/8|. If BL is not less than |Min/8|, the NO path from block 520continues to block 514 in which the electrical stimuli is declared toineffectively capture the ventricle. If BL is less than |Min/8|, thenthe YES path continues to optional block 510.

The YES path from block 508 also continues to block 510 which determineswhether Tmin is less than a preselected value such as 60 ms. Thepreselected value can be any value between 40 ms-80 ms. If Tmin is notless than 60 ms, then the NO path continues to optional block 516 inwhich another determination is made as to whether Max−Min is greaterthan 3.5 mV. If Max−Min is greater than 3.5 mV, effective capture existsand the YES path continues to block 512 in which the ventricularstimulus is declared to capture the ventricle. The NO path from block516 continues to block 514 in which a determination is made thatventricular stimulus is determined not to effectively capture aventricle.

Returning to block 510, if Tmin is less than 60 ms, then the YES pathcontinues to block 512 in which effective capture is declared. Everytime effective capture is declared at block 512, an effective capturecounter is incremented by 1. The effective capture counter is maintainedand updated continuously during effective capture monitoring. Effectivecapture monitoring determines whether pacing stimulus is effective orineffective. Effective capture monitoring tracks responses from cardiactissue during pacing therapy.

Effective capture monitoring may be performed continuously or, morepreferably, performed periodically (e.g. 100 beats/hour (hr), dailyetc.) in order to conserve battery life. Preferably, effective capturemonitoring is performed 100 beats per hour and consists of normal pacetimings (not the ideal timing conditions of ECT). The effective capturemonitoring (i.e. 100 beats per hour) is reported to the user as a % ofeffective capture beats. The user can apply any choice of threshold forconcern (e.g. 90%, etc.).

After a period of monitoring, a metric of effective capture can becomputed by dividing the effective capture counter by the total numberof paced beats. The method then returns to monitoring for the next pacedevent at block 502.

Morphological features are parsed from an EGM and are used to determinewhether pacing is effectively capturing a ventricle. Exemplarymorphological features include maximum value (Max), timing of maximumvalue (Tmax), minimum value (Min), timing of minimum value (Tmin),baseline value (BL) of the EGM amplitude at the time at which pace wasdelivered. The morphological features are evaluated within a time-windowof pre-specified width (i.e. 200 ms) starting at the time of delivery ofpacing.

To determine if effective LV capture can occur under ideal conditions,an effective capture test (ECT) is performed periodically (e.g. daily,etc.), upon the direction of a user (e.g. while the patient sleeps suchas at night time), or in response to consistent observation ofineffective capture. Generally, ideal conditions relate to delivering apacing stimulus at an adequate amplitude and time.

The result of the ECT can be used to explain reasons for the observationof ineffective capture throughout the day. For example, if a leftventricular lead is dislodged, if scar tissue develops at the locationof LV pacing, or if BV pacing includes substantial pre-excitation of theRV, it may not be possible to obtain effective LV capture even underideal conditions.

The ECT test can be performed for LV only pacing or BV pacing. Themanner in which the ECT is performed depends upon whether the patient isexperiencing atrial fibrillation (AF). AF generally results in switchingof pacing behavior to a pacing mode that does not track atrialactivation (e.g., DDI, DDIR, WI, or VVIR pacing modes). When not in AF,the device generally is operating in a pacing mode that tracks atrialactivation, such that SAV and PAV are relevant pacing timing parameters.For example, if the patient is not in AF, LV-only pacing employs a veryshort PAV (e.g. 10 ms) or SAV (e.g. 10 ms). Alternatively, if thepatient is experiencing AF, LV-only pacing employs an overdrive rate.Test beats (e.g. 5 test beats, etc.) are delivered to a ventricle todetermine whether the ventricle was effectively captured in accordancewith the criteria presented in FIG. 4 and the accompanying text. If, forexample, 75% of the tested beats such as 4 of 5 beats are effectivelycaptured, the ECT is passed for that day. Passing the ECT for that daymeans that effective capture is at least possible under idealconditions. Effective capture by electrical stimuli occurs when at least75% of the number of tested days (i.e., 31 out of 40 days) passed theECT.

The BV test follows the LV test. For the BV test, a very short PAV orSAV is used along with the currently programmed W delay if the patientis not in AF, and an overdrive rate is employed if the patient is in AF.Again, 5 test beats are delivered with BV pacing, and 4 of 5 must passeffective LV capture. LV paced beat or BV paced beat is deemed toprovide effective capture if the morphological features satisfy theeffective capture test (ECT). The ECT can comprise one, two or three ofthe following relationships:

Tmax−Tmin>30 ms  (1)

0.2<|Max−BL|/|BL−Min|<5 or (|Max−BL|/|Min−BL|≦LL and BL<|Min/8|)  (2)

and

Tmin<60 ms or Max−Min>3.5 mV  (3)

All timing parameters are measured from the time at which the pace isdelivered.

Table 1 summarizes exemplary method 500 diagnostic data. The twodifferent examples of diagnostic data, shown in FIGS. 5 and 6, depict Rwaves from the QRS complex of the cardiac cycle. The R wave, adepolarization of the ventricles, generally has an amplitude greaterthan any other wave of the cardiac cycle and is characterized by a rapiddeviation from and return toward baseline.

FIG. 5 shows a negative deflection preceding a positive deflection whileFIG. 6 depicts a positive deflection preceding a negative deflection ofthe signal. A negative deflection occurs when a curve falls below thebase line. A negative deflection indicates that a recorded far fieldwave has traveled away from one of the electrodes on a lead. Incontrast, a positive deflection occurs when a curve rises above the baseline as depicted in FIG. 6. The positive deflection means the recordedfar field wave has traveled toward the electrode.

Turning now to the application of the ECT criteria, the pacing datapresented in FIG. 5 delivered effective pacing to capture the ventriclesince blocks 506, 508 and 510 of FIG. 4 were successfully passed. Pacingdata presented in FIG. 6 ineffectively captured the ventricle sinceTmax−Tmin is not greater than 30 ms as to block 506. Table 1 lists theECT criteria along with each result for the pacing data presented inFIGS. 5 and 6.

TABLE 1 Summary of two different pacing effectiveness examples.Parameter or condition Example 1—FIG. 5 Example 2—FIG. 6 Tmax 78.4 ms 83.4 ms Tmin 33.4 ms 144.6 ms BL −1 −5 Min −110 −10 Max 99 88 Tmax −Tmin > 30 78.4 − 33.4 > 0 83.4 − 144.6 is less than zero; therefore,pacing stimulus does not effectively capture 0.2 < |Max − BL|/|BL − 0.2< |.99| < 5 Does not test for this Min| < 5 condition Tmin < 60 ms 33.4ms < 60 ms Does not test for this condition Effectively pacing? Yes No

The conditions for classifying a paced beat as effective or ineffectivecapture can be conveniently displayed as a two-dimensional scatter plot.FIGS. 7A-7C support conditions found in the flow chart of FIG. 4. FIGS.7A-7B depict a LVtip-RV coil EGM. The EGM amplitude, along the Y-axis,extends from −128 to 128 while the X-axis extends from 0 to 0.2 seconds.Data such as BL, Min, Max, Tmin, Tmax are shown for each stimuli and arecompared to the criteria for effective capture. The data is then mappedonto the scatter plot of FIG. 7C. As shown, effective capture existswithin the boxed area from the stimuli delivered from FIG. 7A whileineffective capture exists outside of the boxed area as evoked from theelectrical stimuli delivered from FIG. 7B. Note that the third criterionfor effective capture (Tmin<60 ms or Max−Min>3.5 mV) is not included inthis graphical depiction and is not required for effective capturedetermination in one or more other embodiments.

After ineffective capture has been determined to exist for a substantialportion of paced beats over a period of follow-up and diagnostic datahas been collected by an IMD 16, diagnostic method 600 shown in FIG. 8presents diagnostic classifications that explain the reason for theineffective capture. Ineffective capture can result from insufficientenergy delivery to the ventricle, a poor pacing substrate (i.e.,ventricular tissue that is inexcitable), or poor pace timing. Thediagnostic method advantageously employs the results from leftventricular capture management (e.g. left ventricular capture management(LVCM) etc.) to determine if the delivered energy is sufficient foreffective capture. LVCM is a set of computer instructions, executed bythe processor, that automatically monitors and, if applicable, adjustsLV output to attempt to secure ventricular capture. LVCM can minimize LVoutput that is delivered to capture the left ventricle, while enforcinga safety margin of amplitude over the required amplitude for ventricularcapture, in order to reduce undesirable effects of electricalstimulation such as phrenic nerve stimulation. LVCM can also indicatethat left ventricular capture cannot be obtained, even with high energydeliveries.

Diagnostic method 600 uses daily test results 680 (i.e. using the ECT)and CMR results 682 to determine a diagnosis. The diagnostic methodbegins at block 602 in which at least one of two differentdeterminations can be made such that LVCM is OFF or is ON with anineffective safety margin (i.e., a safety margin less than apredetermined amount of volts (e.g. less than 0.5 volts, less than 1volt etc.).

The NO path from block 602 continues to block 604 in which adetermination is made as to whether LVCM threshold on output is greaterthan a predetermined level (e.g. 6 volts, etc.). If the LVCM thresholdis greater than 6 volts, then the YES path continues to block 606 andpossible loss-of-capture (LOC) is indicated as a diagnosticclassification. A LOC signal is optionally generated and sent to agraphical user interface (GUI) of a programmer for the user.

Returning to block 602, if either of the listed conditions are present,the diagnostic method then performs two different paralleldeterminations. One YES path continues to block 606 which indicatespossible LOC. Another YES path from block 602 continues to block 608 toseek additional reason(s) for ineffective capture. At block 608, if lessthan or equal to 75% of the periodic (e.g. daily) LV-only ECT tests pass(i.e., the “NO” path), then effective capture cannot be achieved underideal timing conditions. This occurs if either the delivered pacingenergy is insufficient (i.e., loss of capture, block 606) or if the leadis pacing into generally inexcitable tissue (i.e., poor pacingsubstrate, block 611). Block 610 separates these two conditions. Atblock 610, determinations are made as to whether Tmax is greater thanTmin and also whether Tmin is greater than or equal to 60 ms for greaterthan or equal to 75% of the daily tests. If both conditions are met,then the YES path continues to block 611 and the LV lead is determinedto be located in a poor substrate (e.g. scar tissue etc.). Thedetermination that the LV lead is located in a poor substrate is thendisplayed on a GUI of the programmer to a user. In contrast, if Tmax isnot greater than Tmin or Tmin is less than 60 ms for greater than orequal to 75% of the tests, then the NO path continues to block 606,which indicates a possible LOC.

Returning to block 608, if the determination is made that LV-only ECTwere successful greater than 75% of the days when a test was conducted,then the YES path is followed to block 612. At block 612, adetermination is made as to whether BV ECT were successful for greaterthan or equal 75% of the days when a test is conducted. If this BV ECTcondition is not met, then the NO path continues to block 614. At block614, a determination is made as to whether RV is pre-excited. RV ispre-excited when the RV pace is delivered before the LV pace, i.e.,RV−LV>0. If RV is programmed to pre-excitation, then the YES pathcontinues to block 616 in which RV pre-excitation is declared. Theprocessor generates a signal causing RV pre-excitation to be displayedon a GUI associated with the programmer. RV pre-excitation can be easilyaddressed through an automated adjustment of delivering the paced event.Alternatively, if RV−LV≦0, then the NO path continues to block 618 inwhich a determination is made as to whether the time between prematuredelivery of an LV pace (LVp) to sensing of ventricular activation by aright ventricular lead (RVR, thus forming an “LVp-RVR” conduction time)is less than 80 ms. If LVp-RVR is less than 80 ms during pacing at avery short A-V delay, the LV and RV leads are in close physicalproximity to one another.

If LVp-RVR is not less than 80 ms, then at block 620, the term “unknown”is displayed to the user on a GUI associated with the programmer.Further evaluation of the “unknown” condition is performed by othermeans. For example, the user may need to obtain and evaluate other datarelated to the patient. In contrast, if LVp-RVR is less than 80 ms, thenat block 622, the “LV and RV leads are too close” is displayed to theuser on a GUI associated with the programmer. The user may then considerphysical or electrical repositioning of one or both the LV lead and/orthe RV lead. Electrical repositioning means choosing a differentelectrode from which to pace.

Returning to block 612, if the data successfully passes the BV ECT, thenthe YES path continues to perform parallel determinations, usingeffective capture monitoring results (CMR), at blocks 624, 628 and 640.CMR is data sensed from the cardiac tissue in response to pacing therapyduring normal pace timing conditions. CMR involves continuous trackingor monitoring of beats for the purpose of reporting how much effectivecapture is occurring, which, in turn, indicates CRT effectiveness.

Skilled artisans will appreciate that multiple ways exist for trackingineffective LV capture that occurred during (1) AF, (2) AS-BV, (3)AP-BV, (4) AS-LV, or (5) AP-LV. For example, when an ineffective LVcapture beat occurs, counters can be used to track when that beatoccurred during a particular condition such as during (1) AF, (2) AS-BV,(3) AP-BV, (4) AS-LV, or (5) AP-LV. At block 624, a determination ismade as to whether greater than or equal to 25% CMR had ineffective LVcapture that occurred during atrial tachycardia/fibrillation (AT/AF). Ifgreater than or equal to 25% CMR indicates ineffective LV capture thatoccurred during AT/AF, then the YES path continues to block 626 in whichAT/AF is indicated to be present. An AT/AF diagnostic signal isoptionally generated and displayed on the GUI such as the exemplary GUIshown in FIG. 10. As noted, the effective ventricular pacing (VP) ismerely 65% which is far below the desired level of 90% or greatereffective VP. Other valuable data such as battery life, alerts (e.g.invalid data, electrical reset, RRT and low battery voltage are alsoincluded).

At block 628, a determination is made as to whether greater than orequal to 25% CMR indicates ineffective LV capture occurred during atrialpace (AP)-BV or atrial sense (AS)-BV. The YES path continues to block630 in which a determination is made as to whether more ineffective LVcapture occurred during AS-BV or AP-BV. The YES path continues to block632 in which long SAV during BV is determined to exist. The NO path fromblock 630 continues to block 620 which indicates an “unknown”explanation thereby possibly prompting further evaluation by the user.

At block 636, a determination is made as to whether more ineffective LVcapture occurred during AP-BV than during AS-BV. If the number ofineffective LV capture beats during AP-BVs is greater than or equal tothe number of ineffective LV capture beats during AS-BVs, the YES pathcontinues to block 638 in which a long PAV during BV is determined toexist. FIG. 11 is an exemplary GUI that shows valuable data to the user.For example, effective VP is 65% which is less than the desired 90% orgreater effective VP. Additionally, the GUI indicates that theineffective pacing is likely due to (1) AT/AF and (2) long PAV duringBV. While adjustment can be automatically made to address the PAV thatis too long, the user can optionally control any adjustment throughmanual input.

Returning to block 618, the NO path continues to block 620 in which anunknown result is displayed, which may prompt the user to continue toseek additional data. At block 640, a determination is made as towhether ineffective LV capture is occurring during AP-LV+AS-LV>25% CMR,as described above. At block 642, if AS-LV counter>AP-LV counter, thenthe YES path continues to block 644 in which a GUI displays that a longsensed atrioventricular delay (SAV) is occurring during LV.

If the AS-LV counter is less than or equal to AP-LV counter at block642, then the NO path continues to block 620 which indicates an“unknown” explanation.

At block 646, a determination is made as to whether AP-LV counter isgreater than or equal to a AS-LV counter. If so, then the YES pathcontinues to block 648, which indicates that a long pacedatrioventricular delay (PAV) during BV. The long PAV during LV is thendisplayed on a GUI. Alternatively, if AP-LV counter is less than or lessthan a AS-LV counter.

An additional means of explaining reasons for loss of effective captureis storage of episodes with consistent runs of ineffective capturebeats. These “ineffective capture episodes” (ICE) are acquired by thedevice when a consecutive number of CRT beats resulted in ineffectivecapture. A typical threshold employed by the device could be 10consecutive CRT beats that result in ineffective capture. Theineffective capture episodes can be displayed (e.g. FIG. 12) to the userfor interpretation and appropriate corrective action. An automatedalgorithm to explain the reason for each ineffective capture episodewould facilitate this interpretation and corrective action. FIG. 9 is aflow chart of an exemplary diagnostic method 700 for explainingineffective capture episodes. Method 700 is the same as method 600except as modified below. Diagnostic method 600 relies on daily testresults 702 (i.e. through employing the ECT) and CMR results 704 todetermine a diagnosis. At block 660, a determination as made as towhether the most recent or latest ECT for LV pacing is successful. Ifthere is no effective LV capture, the NO path continues to block 606where LOC is declared. In contrast, a recent ECT allows the YES path tocontinue to block 668 in which a determination is made as to whether themost recent effective capture test was performed for biventricularpacing. At block 670, a determination is made as to whether the V rateis below a preselected upper tracking rate. An upper tracking rate isprogrammed by the user to be the highest sinus tachycardia rate that thedevice will track with ventricular pacing. A common value for the uppertracking rate is 120 BPM. If the ventricular rate (V rate) is not belowa preselected upper tracking rate, then the NO path continues to block672 in which the upper tracking rate is declared as requiringadjustment. If the V rate is below a preselected upper tracking rate,then the NO path continues to a set of parallel determinations as setforth relative to blocks 674, 676, 678, 680, and 682.

At block 674, a series of determinations are made. One determination iswhether the A rate is greater than 160 beats per minute (BPM). Anotherdetermination is whether AT/AF is present or whether no far-field R-wave(FFRW) is present. Yet another determination is whether the A rate isgreater than the V rate. If all three conditions are true, then the YESpath continues to block 626. At block 676, a determination is made as towhether greater than 25% ineffective capture episode (ICE) ventricularevents are classified as AS-biventricular pacing. Therefore, out of 10consecutive beats without effective LV capture, a further determinationis made as how many beats were AS-BV, how many beats were AP-BV, etc.

Returning to block 636, the YES path continues to block 638 in which along PAV during BV is declared.

At block 678, a determination is made as to whether greater than 25% ICEventricular events are AP-BV. If so, the YES path continues to block 638in which a long PAV during BV is declared.

At block 680, a determination is made as to whether greater than 25% ICEventricular events are AS-LV. If so, the YES path continues to block 644in which a long SAV during LV is declared. At block 682, a determinationis made as to whether greater than 25% ICE Ventricular events are AP-LV.If so, the YES path continues to block 648 in which a long PAV during LVis declared.

FIG. 13 is a flow chart of method 800 in which one or more automatedactions are implemented by IMD 16 in response to determining ineffectivecapture of a ventricle. Ineffective capture is due to a diagnosticclassification described relative to FIGS. 8-9. Exemplary automatedactions include switching pacing vectors and/or modifying the SAV/PAV.Automated actions are only implemented if there is a persistent problemwith ineffective capture over a period time (e.g. several days, lessthan a week etc). For example, if ineffective capture persists over aweek due to a LOC or a lead is located in scar tissue, alternate pacingvectors may be tested for lower thresholds and the IMD 16 canautomatically change the pacing vector if other vectors are available.

If the reason for ineffective pacing is PAV or SAV related, the IMD 16initiates an automated action in which PAV or SAV are iterativelyreduced by small decrements (e.g. 10 ms or less) and effective captureis then evaluated during delivery of therapy at the reduced PAV/SAV. Ifeffective capture is determined to exist at the reduced PAV/SAV, thelatest PAV/SAV is set as the maximum permissible PAV/SAV duringsubsequent delivery of therapy. For example, if the algorithm for IMD 16performs an automatic calculation of SAV/PAV and determines a value ofPAV/SAV that is less than this value, the IMD 16 calculated SAV/PAV isused for therapy. However, if the IMD 16 calculated SAV/PAV is a highervalue than the SAV/PAV set in IMD 16, the newly calculated SAV/PAV isrejected in favor of the maximum permissible PAV/SAV.

Skilled artisans appreciate that the data register for the maximumPAV/SAV can be automatically cleared after a predetermined timeoutperiod (e.g., 1-10 minutes etc.) and the process is repeated forobtaining the maximum PAV/SAV. Clearing the maximum PAV/SAV dataregister after a timeout period can ensure that the maximum PAV/SAV canbe used to accommodate changing physiological conditions.

Automated action method 800 begins at block 802 in which a determinationis made as to whether effective capture is less than a predeterminedthreshold for the latest period of time (e.g. 5 days). Skilled artisansappreciate that an exemplary predetermined threshold can be set at 80%and could range from, for example, 98% to 50%. Additionally, while thelatest period of time could be set at 5 days, it should be appreciatedthat the latest period of time could range from 1 hour to 14 days. Atblock 804, the reason for ineffective capture is accessed by processor80 from memory 82, which was previously determined through FIGS. 8-9. Atblock 806, a determination is made as to whether LOC or a lead islocated in scar tissue. The YES path from block 806 continues to block818. At block 818, thresholds of alternative pacing vectors areevaluated via the LVCM routine or other capture threshold determinationmeans. At block 828, a determination is made as to whether one or morethresholds is lower than the current threshold. If the threshold islower than the current threshold, the YES path continues to block 836. Arecommendation can be automatically implemented by IMD 16 to switch tothe vector with a lower threshold. Returning to block 828, the NO pathcontinues to block 811 to allow a determination to be made as to whethermore pacing vectors are available. If there are no other pacing vectorsavailable, the NO path continues to block 812 and no action is taken. Incontrast, if more pacing vectors are available, then the YES pathcontinues from block 811 to block 818 and thresholds are again evaluatedto locate a preferred pacing vector to attain effective capture.

The NO path from block 806 continues to a series of paralleldeterminations that are made at blocks 808, 810, 814, and 816. At block808, a determination is made as to whether a long SAV exists during LVp.If not, no action is performed at block 812. If long SAV is presentduring LVp, then the YES path continues from block 808 to block 820 inwhich SAV-LVp is reduced or decremented. The present value for SAV-LVpis decremented by a preselected value (e.g. 10 ms or less). At block830, a determination is made as to whether effective capture is attainedat the new SAV-LVp. If effective capture is attained, the new SAV-LVp isset as the maximum permissible SAV-LVp at block 838. In contrast, ifeffective capture is not attained, then the path continues from block830 to block 820 in which the SAV-LVp is again decremented and evaluatedfor effective capture.

At block 810, a determination is made as to whether a long PAV isoccurring during LV pacing. The NO path from block 810 continues toblock 812 in which no action is implemented. The YES path continues toblock 822 in which the PAV-LVp is automatically reduced. A reduction inthe PAV-LVp is preferably 10 ms or less. Thereafter, a determination ismade as to whether effective capture exists through implementation ofthe updated or latest PAV-LVp by IMD 16 at block 832. If effectivecapture is not occurring with the updated or latest PAV-LVp, the NO pathfrom block 832 returns to block 824 which again reduces the PAV-LVp andthen rechecks whether effective capture is being achieved using thelatest PAV-LVp. Returning to block 832, once a determination is madethat the latest PAV-LVp achieves effective capture, the latest PAV-LVpis set as the maximum permissible PAV-LVp at block 840.

Returning to another NO path extending from block 806, a determinationis made as to whether a long SAV is present during BV pacing at block814. At block 824, the SAV-BV pacing is reduced by about 10 ms or lessfrom the latest SAV-BV pacing setting. Thereafter, a determination ismade as to whether effective capture exists through implementation ofthe updated or latest SAV-BVp by IMD 16 at block 834. If effectivecapture is not occurring with the updated or latest SAV-BVp, the NO pathfrom block 834 returns to block 824 which again reduces the SAV-BVp andthen rechecks whether effective capture is being achieved using thelatest SAV-BVp. Returning to block 834, once a determination is madethat the latest SAV-BVp achieves effective capture, the latest SAV-BVpis set as the maximum permissible SAV-BVp at block 842.

Returning to yet another NO path that extends from block 806, adetermination is made as to whether a long PAV is present during BVpacing at block 816. At block 826, the PAV-BV pacing is reduced by about10 ms or less from the latest PAV-BV pacing.

Thereafter, a determination is made at block 837 as to whether effectivecapture exists through implementation of the updated or latest PAV-BVpby IMD 16. If effective capture is not occurring with the updated orlatest PAV-BVp, the NO path from block 836 returns to block 826 whichagain reduces the PAV-BVp and then rechecks whether effective capture isbeing achieved using the latest PAV-BVp. Returning to block 836, once adetermination is made that the latest PAV-BVp achieves effectivecapture, the latest PAV-BVp is set as the maximum permissible PAV-BVp atblock 844.

As to FIG. 13, skilled artisans will appreciate that one or more of theactions can be presented to a user on a GUI before an action isimplemented. Other exemplary GUIs are shown in FIGS. 14-15. FIG. 14, forexample, depicts a GUI that allows for programming of device alerts forthe condition of low % effective LV capture. This alert, for example,can be programmed to respond to observation of a consecutive number ofdays (e.g. 7 days in this case) where the measured % effective LVcapture is below a threshold value (e.g., 90% in this case). Alerts canbe of assistance to prompting a patient to visit his or her doctor, orprompting the doctor directly to consider taking some corrective action.FIG. 15 depicts a GUI such as a Medtronic Cardiac Compass Report thatreports trends over long durations of time, thus allowing a doctor tomonitor heart function activity and the function of IMD 16. The additionof a daily trend of % effective LV capture to this display may help thedoctor to determine the cause of loss of % effective LV capture as itrelates to other physiological changes in the patient.

Additionally, the automated actions of FIG. 10 are not implementedduring fast rhythms (e.g. average or median ventricular rate is greaterthan 100 bpm or average atrial rate is greater than 100 bpm) and otherconditions of rate or rhythm in which LVCM is aborted.

Skilled artisans will also appreciate that the present disclosureencompasses embodiments in which method 600 and/or method 700 areconfigured to allow at most two diagnostic classifications. Afterreaching the second diagnostic classification, processing can shut downand IMD 16 returns to monitoring.

Skilled artisans appreciate that the ECT can be expressed with respectto positive deflection and negative deflection. For example, the presentdisclosure encompasses an apparatus for determining whether aventricular pacing stimulus is capturing a paced ventricle duringcardiac resynchronization therapy that comprises delivering aventricular pacing stimulus and then sensing a signal in response to theventricular pacing stimulus. A determination is made as to whether apositive deflection of the signal precedes a negative deflection of thesignal. Thereafter, a determination is made as to whether theventricular pacing stimulus is capturing the paced ventricle in responseto determining whether the positive deflection precedes the negativedeflection. The ventricular pacing stimulus does not capture theventricle when the positive deflection precedes the negative deflection.Skilled artisans appreciate that a sensing scheme with a reversepolarity as that which is disclosed herein is still contemplated to bewithin the scope of the invention. For example, if a reverse polarity isused in sensing a physiological response, the opposite result wouldoccur (i.e. ventricular pacing stimulus does capture the ventricle whenthe positive deflection precedes the negative deflection).

The techniques described in this disclosure, including those attributedto the IMD 16, the programmer 24, or various constituent components, maybe implemented, at least in part, in hardware, software, firmware, orany combination thereof. For example, various aspects of the techniquesmay be implemented within one or more processors, including one or moremicroprocessors, DSPs, ASICs, FPGAs, or any other equivalent integratedor discrete logic circuitry, as well as any combinations of suchcomponents, embodied in programmers, such as physician or patientprogrammers, stimulators, image processing devices, or other devices.The term “module,” “processor,” or “processing circuitry” may generallyrefer to any of the foregoing logic circuitry, alone or in combinationwith other logic circuitry, or any other equivalent circuitry.

Such hardware, software, and/or firmware may be implemented within thesame device or within separate devices to support the various operationsand functions described in this disclosure. In addition, any of thedescribed units, modules, or components may be implemented together orseparately as discrete but interoperable logic devices. Depiction ofdifferent features as modules or units is intended to highlightdifferent functional aspects and does not necessarily imply that suchmodules or units must be realized by separate hardware or softwarecomponents. Rather, functionality associated with one or more modules orunits may be performed by separate hardware or software components, orintegrated within common or separate hardware or software components.

When implemented in software, the functionality ascribed to the systems,devices and techniques described in this disclosure may be embodied asinstructions on a computer-readable medium such as RAM, ROM, NVRAM,EEPROM, FLASH memory, magnetic data storage media, optical data storagemedia, or the like. The instructions may be executed by one or moreprocessors to support one or more aspects of the functionality describedin this disclosure.

Listed below are co-pending U.S. patent applications that describevarious aspects of the apparatus and methods described herein. Theco-pending applications are incorporated by reference in theirentireties.

Co-pending U.S. patent application Ser. No. ______ entitled “EFFECTIVECAPTURE” filed by Subham Ghosh et al. and assigned to the same assigneeof the present disclosure.

Co-pending U.S. patent application Ser. No. ______ entitled “EFFECTIVECAPTURE” filed by Subham Ghosh et al. and assigned to the same assigneeof the present disclosure.

Co-pending U.S. patent application Ser. No. ______ entitled “EFFECTIVECAPTURE” filed by Subham Ghosh et al. and assigned to the same assigneeof the present disclosure.

This disclosure has been provided with reference to illustrativeembodiments and is not meant to be construed in a limiting sense. Asdescribed previously, one skilled in the art will recognize that othervarious illustrative applications may use the techniques as describedherein to take advantage of the beneficial characteristics of theapparatus and methods described herein. Various modifications of theillustrative embodiments, as well as additional embodiments of thedisclosure, will be apparent upon reference to this description.

What is claimed:
 1. An apparatus for automatically adjusting a settingafter determining a reason for ineffective capture of a ventricle,comprising: means for delivering a ventricular pacing stimulus; sensingmeans for sensing a signal in response to the ventricular pacingstimulus; processing means for extracting data from the signal;processing means for determining whether ineffective capture of theventricle is occurring based upon the sensed data; storing means forstoring data as to ineffective capture of the ventricle; processingmeans for determining the reason for ineffective capture; processingmeans for determining whether ineffective capture persists for apredetermined amount of time; and processing means for automaticallyadjusting the setting that addresses the reason for ineffective capture.2. The apparatus of claim 1 wherein the processing means forautomatically adjusting the setting further comprises: processing meansfor determining whether a long SAV exists during LVp: processing meansfor reducing a SAV-LVp by a predetermined amount of time for a newSAV-LVp; processing means for activating the new SAV-LVp; means fordetermining whether effective capture of the ventricle is attainedthrough using the new SAV-LVp; and means for replacing the SAV-LVp withthe new SAV-LVp if effective capture is attained with the new SAV-LVp.3. The apparatus of claim 1 wherein the processing means forautomatically adjusting the setting further comprises: processing meansfor determining whether a long PAV exists during LVp; processing meansfor reducing a PAV-LVp by a predetermined amount of time for a newPAV-LVp; processing means for activating the new PAV-LVp; means fordetermining whether effective capture of the ventricle is attainedthrough using the new PAV-LVp; and means for replacing the PAV-LVp withthe new PAV-LVp if effective capture is attained with the new PAV-LVp.4. The apparatus of claim 1 wherein the processing means forautomatically adjusting the setting further comprises: processing meansfor determining a long SAV exists during BVp; processing means forreducing a SAV-BVp by a predetermined amount of time for a new SAV-BVp;processing means for activating the new SAV-BVp; means for determiningwhether effective capture of the ventricle is attained through using thenew SAV-BVp; and means for replacing the SAV-BVp with the new SAV-BVp ifeffective capture is attained with the new SAV-BVp.
 5. The apparatus ofclaim 1 wherein the processing means for automatically adjusting thesetting further comprising: processing means for determining whether along PAV exists during BVp; processing means for reducing a PAV-BVp by apredetermined amount of time for a new PAV-BVp; processing means forimplementing the new PAV-BVp; means for determining whether effectivecapture of the ventricle is attained through using the new PAV-BVp; andmeans for replacing the PAV-BVp with the new PAV-BVp if effectivecapture is attained with the new PAV-BVp.
 6. The apparatus of claim 1wherein the processing means for automatically adjusting the settingfurther comprising: processing means for determining whether more pacingvectors are available.
 7. The apparatus of claim 1 further comprising:processing means for switching an existing pacing vector with a newpacing vector.
 8. An apparatus for automatically adjusting a settingafter determining a reason for ineffective capture of a ventricle,comprising: means for delivering a ventricular pacing stimulus; sensingmeans for sensing a signal in response to the ventricular pacingstimulus; processing means for extracting data from the signal;processing means for determining whether ineffective capture of theventricle is occurring based upon the sensed data; storing means forstoring data as to ineffective capture of the ventricle; processingmeans for determining the reason for ineffective capture; processingmeans for determining whether ineffective capture persists for apredetermined amount of time; and processing means for automaticallyswitching an existing pacing vector with a new pacing vector thataddresses the reason for ineffective capture.
 9. An apparatus forautomatically adjusting a setting after determining a reason forineffective capture of a ventricle, comprising: means for delivering aventricular pacing stimulus; sensing means for sensing a signal inresponse to the ventricular pacing stimulus; processing means forextracting data from the signal; processing means for determiningwhether ineffective capture of the ventricle is occurring based upon thesensed data; storing means for storing data as to ineffective capture ofthe ventricle; processing means for determining the reason forineffective capture; processing means for determining whetherineffective capture persists for a predetermined amount of time; andprocessing means for automatically swapping pacing vectors in responsefor determining the reason for ineffective capture.
 10. A method for animplantable medical device (IMD) automatically adjusting a setting onthe IMD after determining a reason for ineffective capture of aventricle, comprising: delivering a ventricular pacing stimulus; sensinga signal in response to the ventricular pacing stimulus; extracting datafrom the signal; determining whether ineffective capture of theventricle is occurring based upon the sensed data; storing data as toineffective capture of the ventricle; determining the reason forineffective capture; determining whether ineffective capture persistsfor a predetermined amount of time; and automatically adjusting thesetting that addresses the reason for ineffective capture
 11. The methodof claim 10 wherein adjusting the setting further comprises: determiningwhether a long SAV exists during LVp: reducing a SAV-LVp by apredetermined amount of time for a new SAV-LVp; activating the newSAV-LVp; determining whether effective capture of the ventricle isattained through using the new SAV-LVp; and replacing the SAV-LVp withthe new SAV-LVp if effective capture is attained with the new SAV-LVp.12. The method of claim 10 wherein automatically adjusting the settingfurther comprises: determining whether a long PAV exists during LVp;reducing a PAV-LVp by a predetermined amount of time for a new PAV-LVp;activating the new PAV-LVp; determining whether effective capture of theventricle is attained through using the new PAV-LVp; and replacing thePAV-LVp with the new PAV-LVp if effective capture is attained with thenew PAV-LVp.
 13. The apparatus of claim 10 wherein automaticallyadjusting the setting further comprises: determining a long SAV existsduring BVp; reducing a SAV-BVp by a predetermined amount of time for anew SAV-BVp; activating the new SAV-BVp; determining whether effectivecapture of the ventricle is attained through using the new SAV-BVp; andreplacing the SAV-BVp with the new SAV-BVp if effective capture isattained with the new SAV-BVp.
 14. The method of claim 10 whereinautomatically adjusting the setting further comprising: determiningwhether a long PAV exists during BVp; reducing a PAV-BVp by apredetermined amount of time for a new PAV-BVp; implementing the newPAV-BVp; determining whether effective capture of the ventricle isattained through using the new PAV-BVp; and replacing the PAV-BVp withthe new PAV-BVp if effective capture is attained with the new PAV-BVp.15. The method of claim 10 wherein automatically adjusting the settingfurther comprising: determining whether more pacing vectors areavailable.
 16. The method of claim 15 further comprising: switching anexisting pacing vector with a new pacing vector.
 17. A method for an IMDto automatically adjust a SAV-LVp on the IMD after determining a reasonfor ineffective capture of a ventricle, comprising: delivering aventricular pacing stimulus; sensing a signal in response to theventricular pacing stimulus; extracting data from the signal;determining whether ineffective capture of the ventricle is occurringbased upon the sensed data; storing data as to ineffective capture ofthe ventricle; determining the reason for ineffective capture;determining whether ineffective capture persists for a predeterminedamount of time; determining whether a long SAV exists during LVp:reducing a SAV-LVp by a predetermined amount of time for a new SAV-LVp;activating the new SAV-LVp; determining whether effective capture of theventricle is attained through using the new SAV-LVp; and replacing theSAV-LVp with the new SAV-LVp if effective capture is attained with thenew SAV-LVp